For any service provided for at least 15 minutes you must bill 1 unit. Sometimes that’s easy: if you provide 15 minutes of Therapeutic Exercise you bill 1 unit of that code, 30 minutes of Neuromuscular Re-education is 2 units of that code. However, this is where Medicare’s totaling of the time complicates things. Say you do:
Full Answer
What is physical therapy Medicare fraud?
Physical therapy Medicare fraud is when a provider fraudulently bills Medicare for physical therapy services. This fraud can also extend to other types of therapy services for Medicare beneficiaries, such as occupational or speech therapy. Physical therapy Medicare fraud is when a provider fraudulently bills Medicare for physical therapy services.
What are the laws against Medicare fraud?
In addition to Medicare Part A and Part B, Medicare Part C and Part D and Medicaid programs prohibit the fraudulent conduct addressed by these laws.
How do I bill Medicare for therapeutic exercise?
Sometimes that’s easy: if you provide 15 minutes of Therapeutic Exercise you bill 1 unit of that code, 30 minutes of Neuromuscular Re-education is 2 units of that code. However, this is where Medicare’s totaling of the time complicates things.
Does Medicare pay for physical therapy?
A common misconception is that Medicare will only cover PT when a patient is improving (getting stronger, moving more independently, gaining flexibility). Often physical therapists discharge patients [with chronic, degenerative conditions] because they do not realize that ongoing skilled maintenance therapy is covered by Medicare.
What is fraud in physical therapy?
Physical therapy fraud is a common form of healthcare fraud that may violate the False Claims Act. It occurs where a provider fraudulently bills Medicare or Medicaid for physical therapy services.
How often does a PT have to see a Medicare patient?
There is no particular format required by Medicare as long as all the above is contained in the note as long as it happens at least once every 10 treatment visits.
What are the consequences of Medicare fraud?
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs' loss plus $11,000 per claim filed.
What is a major part of Medicare fraud?
Misusing codes on a claim, such as upcoding or unbundling codes. Upcoding is when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement. Medicare abuse can also expose providers to criminal and civil liability.
Does Medicare pay for physical therapy at home?
Medicare Part B medical insurance will cover at home physical therapy from certain providers including private practice therapists and certain home health care providers. If you qualify, your costs are $0 for home health physical therapy services.
When should a patient be discharged from physical therapy?
The physical therapist discontinues intervention when the patient/client is unable to continue to progress toward goals or when the physical therapist determines that the patient/client will no longer benefit from physical therapy.
What is the Red Flags Rule healthcare?
The Red Flags Rule requires that organizations have “reasonable policies and procedures in place” to identify, detect and respond to identity theft “red flags.” The definition of “reasonable” will depend on your practice's specific circumstances or specific experience with medical identity theft as well as the degree ...
Which is an example of Medicare abuse?
One example of Medicare abuse is when a doctor makes a mistake on a billing invoice and inadvertently asks for a non-deserved reimbursement. Medicare waste involves the overutilization of services that results in unnecessary costs to Medicare.
What are the civil penalties if a person is found guilty of Medicare fraud?
Furthermore, individuals who have been convicted of Medicare fraud may be ordered to pay fines worth up to $250,000. Professionals who are accused of any of these violations may also face substantial civil fines. The fine for each false claim is $11,000, while the fine for every kickback is $50,000.
How do you handle Medicare fraud?
If you suspect Medicare fraud, do any of these: Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Call the fraud hotline of the Department of Health and Human Services Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950.
Will Medicare call you at home?
Medicare generally won't call you, except in limited circumstances. One such exception is if you have called 1-800-MEDICARE and requested a return call. Medicare will never call or come to your home uninvited to sell products or services.
Do PT boards fight?
Their budgets get cut, and more. The PT board is usually the one doing most of the initial data or evidence gathering and they are the one’s essentially helping build the legal cases against therapists. They are NOT on your side. Most therapists don’t know this. Most therapists do NOT fight .
Is physical therapy a fraud?
Physical Therapy Private Practices Being Charged With Fraud. You never think about physical therapists as being a danger to society, or the country, but that’s the new campaign spearheaded by Medicare and the government. Physical therapists are the “flavor of the month” in the government’s pursuit for more monies in this never ending saga ...
Do therapists fight?
Most therapists don’t know this. Most therapists do NOT fight . The reason being that fighting the PT board and the legal system can take over a year of time, a whole lot of money, and even more stress. Not many attorneys (even healthcare attorneys) know much about physical therapy.
What is heat in Medicare?
The DOJ, OIG, and HHS established HEAT to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent and detect fraud and abuse . HEAT expanded the DOJ-HHS Medicare Fraud Strike Force, which targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.
What is the OIG self disclosure protocol?
The OIG Provider Self-Disclosure Protocol is a vehicle for providers to voluntarily disclose self-discovered evidence of potential fraud. The protocol allows providers to work with the Government to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.
Is there a measure of fraud in health care?
Although no precise measure of health care fraud exists, those who exploit Federal health care programs can cost taxpayers billions of dollars while putting beneficiaries’ health and welfare at risk. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of beneficiaries.
Is CPT copyrighted?
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability of data contained or not contained herein.
Can you give free samples to a physician?
Many drug and biologic companies provide free product samples to physicians. It is legal to give these samples to your patients free of charge, but it is illegal to sell the samples. The Federal Government has prosecuted physicians for billing Medicare for free samples. If you choose to accept free samples, you need reliable systems in place to safely store the samples and ensure samples remain separate from your commercial stock.
How long is Medicare billing?
When billing timed CPT codes, Medicare not only looks at the individual 15-minute units but also considers the total time when factoring the allowable payment. This is commonly known as the 8-23-minute rule.
What does Medicare expect from you?
Medicare expects you to evaluate the patient, determine their rehabilitation needs and address those needs. One of those inaccurate impressions is the belief the patient must be making objective progress in order to continue with rehabilitation.
What does the KX modifier mean for PT?
The KX modifier simply indicates to Medicare that specific treatment continues to be medically necessary and requires the skills of the PT/OT in order to continue towards meeting the patient’s goals. This serves as a mental check on whether the care continues to be reasonable and necessary.
How did Medicare come into existence?
Medicare came into being through legislation, signed into law by President Lyndon Johnson, as part of the Social Security Amendments of 1965. It’s funded by payroll deductions as an addition to your Social Security deductions (FICA) as well as premiums paid for those receiving Part B benefits.
What is important about Medicare?
One of the more valuable things about Medicare is they tell you exactly what they are looking for in their documentation requirements. For starters, documentation must support the medical necessity of the care provided. This means your notes must be comprehensive enough and contain sufficient detail so anyone reviewing the medical record may easily see what you are treating and why you are providing that specific treatment. They should also be able to easily see if there is progress towards achieving the patient’s functional goals.
How many units are needed for 15 minutes of exercise?
For any service provided for at least 15 minutes you must bill 1 unit. Sometimes that’s easy: if you provide 15 minutes of Therapeutic Exercise you bill 1 unit of that code, 30 minutes of Neuromuscular Re-education is 2 units of that code. However, this is where Medicare’s totaling of the time complicates things.
Is it better to audit Medicare or defend?
Of course, the best defense is a good offense. Setting your practice up to comply with the Medicare rules is much better than having to address an audit. To audit proof yourself, be sure you know the rules and regulations on document/billing and fully comply.
How to report Medicaid fraud?
There are two ways of reporting fraud, contacting Medicare (1-800-MEDICARE) or your state Medicaid fraud control unit. Doing that is great and can be anonymous. Doing this does not qualify you for a reward, however.
How much did Scripps pay for physical therapy?
Scripps agreed to pay a penalty of $1.5 million.
How much did Seddon Baldwin pay for Medicare fraud?
Instead of listening to him, he was instead fired. When that happened, he stepped forward and blew the whistle. This month Baldwin Bone & Joint agreed to pay $1.2 million to settle Medicare and Medicaid fraud charges, Seddon was awarded $200,000.
Where did the physiologist blow the whistle?
A recent case from Alabama suggests that isn’t always the case. A former physiologist who worked at the Baldwin Bone & Joint clinic in Baldwin, Alabama blew the whistle on his former employer. He said the clinic was using physiologists, athletic trainers, assistants, and physical therapists interchangeably. Medicare and Medicaid allow physical ...
Who said when non-therapists performed physical therapy, they simply left the billing sheet and progress notes unsigned?
The employee, John Seddon , said when non-therapists performed physical therapy, they simply left the billing sheet and progress notes unsigned. A licensed therapist would later sign off as if they had seen the patient and performed the therapy.
Can an orthopedist refer a patient to an MRI clinic?
That means they can’t try to profit by sending patients to other facilities they or a spouse may own. That means an orthopedist cannot refer a patient to an MRI clinic he owns and then to pharmacy her husband owns.
Can you retaliate against a medicaid worker?
Under state and federal law, it is illegal to retaliate against workers who report Medicaid fraud, even if the report is made internally. Workers who are wrongfully terminated can collect double damages, future lost wages and attorney’s fees.
What happens if your medical documentation is not documented?
If it’s lacking, it could leave you in hot water with Medicare auditors.
Does CMS expect you to stay up to date?
And let’s face it: keeping up with those changes can be a challenge. But, CMS expects you to stay up to date, and failing to do so could lead to some major red flags. Common code-related warning signs include:
Do questionable billing practices catch up with you?
No matter how fast you are, questionable billing practices will always catch up with you. If and when they do, you better be ready to defend yourself with defensible documentation. With a healthy dose of vigilance—and the right tools to keep your documentation up to snuff—you’ll be ready for anything CMS throws at you.
Is it acceptable to bill Medicare for services rendered by a student?
(For example, it’s never acceptable to bill Medicare for services rendered by a student.) Subscribing to educational resources like CMS email updates, APTA news releases, and the WebPT Blog can help you stay in the know on Medicare rules and compliance changes. (If you’re wondering whether your billing knowledge is up to snuff, be sure to take our billing blunders quiz .) Additionally, if your EMR platform features built-in compliance alerts and safeguards, it can help you catch smaller errors such as underbilling and 8-minute rule noncompliance.
What to do if you have witnessed fraud?
If you’ve witnessed any of these situations in your workplace (or anything else that you believe to be fraudulent, abusive, or wasteful), here are some things you can do about it: 1. Talk to your supervisor or compliance officer.
Can a provider stop fraud?
Providers who suspect fraud or abuse should immediately stop participating in the concerning activity and speak with their supervisor. Generally speaking, this stands regardless of whether or not the issue is Medicare-related. However, if you’re not comfortable taking that path, you can go to another supervisor within your organization or reach out to your organization’s compliance officer .
Why do physical therapists discharge patients?
Often physical therapists discharge patients [with chronic, degenerative conditions] because they do not realize that ongoing skilled maintenance therapy is covered by Medicare.
Can you do PT on your own?
There are times when a short course of physical therapy (PT) can meet your current needs, and you can then continue exercises on your own. Other times, however, ongoing PT may be necessary to maintain your current status (strength, flexibility, mobility, etc.) and to prevent further deterioration of your condition.
Can a therapist give you a home program?
The therapist can give you a home program, but continue to periodically re-evaluate you, address new needs, and modify your home program, or. The therapist can personally provide ongoing skilled maintenance therapy due to safety and/or complexity of your situation.